Tuesday 8 November 2005 21.12 EST
First published on Tuesday 8 November 2005 21.12 EST

So what will Patricia Hewitt do now? When Tony Blair appointed her as health secretary in May, they were both clear the next big leap forward for NHS reform in England should be to introduce competition in primary care - or "contestability".

December was pencilled in for a white paper on healthcare outside hospitals, where 90% of patient consultations take place. Hewitt knew that few of the providers of these services would relish moving into a more commercial business environment. GPs, district nurses, chiropodists, physiotherapists, family planning counsellors and other members of the NHS's 250,000-strong workforce outside hospitals would probably object when told they had to compete for custom - with each other and the private sector.

To bolster her argument, Hewitt set up an exercise to listen to what patients want. A series of citizens' juries were brought together by the consultants Opinion Leader Research, culminating in an event in Birmingham last month when nearly 1,000 people worked in small groups to hammer out a patients' vision of primary care improvements.

Option for change

The trouble for Hewitt was that this "citizen's summit" did not produce all the answers Hewitt wanted. The representative national panel of patients was presented with five main options for change. Everyone was told they had 10 points to award. They could pick one option and award it 10 out of 10, leaving no points for the others, or they could distribute the points according to relative preference. The results were totted up to produce an average. It showed strong support for making NHS services outside hospital more convenient for patients:

· "Extending opening hours to evenings and weekends at the local GP practice, pharmacy and other community services" scored 3.7 points out of 10.

· "Providing more NHS walk-in centres in convenient locations so people can get quick advice on problems and health issues - for example, near train stations or in city centres" scored 2.7 points.

· "Letting people choose to see someone other than a doctor - for example, a nurse practitioner or a pharmacist - so they can get a more convenient appointment" scored 2 points.

That left tiny scores for options that could have introduced contestability:

· "Allowing people to register with any doctor, not just one where they live" scored 0.9.

· "Allowing people to self-refer, in defined circumstances, to someone of their own choice for some services, so they don't need to see their GP first to get a referral" also scored 0.9.

The numbers added up to slightly more than 10, due to rounding. But they also added up to a less than ringing endorsement for the contestability policy on which Hewitt's civil servants are labouring.

Leaders of the discussion groups found people wanted to be able to change their doctor if they didn't like the current one. But they did not want to shop around when they were ill. They feared losing the continuity of seeing a local doctor who knew their medical history. They doubted whether older people without transport - and people of all ages in rural areas - would benefit from extra choices. And the citizens feared that "more choice will mean the best services will be swamped".

In further votes, the citizens' jury gave lukewarm support to moving services out of hospitals into the community. Despite the recent MRSA scare, they said they felt safer in hospitals, and wondered whether community services could cope in an emergency. But they agreed it made sense for diagnostic testing services to be available locally, to avoid a trek to hospital.

This was hardly the mandate Hewitt was seeking. She will have been encouraged by the strong support for her idea of giving everyone the right to an annual health MoT. That came first out of 13 proposals for improving services, with 76% of the panellists in Birmingham voting it among their top three priorities.

But the suggested reform with least support was to "allow other organisations - for example, a charity, Boots, a supermarket - to set up a local health centre for NHS patients". Only 6% of the jury included it in their top three priorities.

The question now is how far she dares to persist with promoting contestability in primary care when it seems to be unpopular with patients as well as providers.

Her instinctive answer is probably to tell people they cannot hope to get the more convenient, consumer-friendly service without the spur of competition being introduced into primary care. But Hewitt must also take into account the political dimension. Across Whitehall, a debate is in progress about the pace of reform in Blair's third term. The parliamentary Labour party has already rattled the cage, expressing strong dislike of her plans to force primary care trusts (PCTs) to contract out all services to other public, voluntary or private sector providers.

In a concession last month, Hewitt said she would not force the PCTs to abandon the provider role. But she has not withdrawn guidance from Sir Nigel Crisp, the NHS chief executive, telling them to do so by 2008. This ambiguity is unlikely to be cleared up quickly. Since the Royal College of Nursing applied to the courts last week for judicial review of Crisp's decision, Department of Health lawyers have advised ministers and officials to keep their mouths shut on the subject.

Labour MPs may not take kindly to the next grievance. Hewitt's department has told strategic health authorities that their forecasts of deficits at the end of the NHS financial year in March are unacceptable. To achieve balance, many hospital trusts will soon have to begin an unpopular winter round of cuts. A murky debate is likely to ensue, with critics seeking to pin blame for the cuts on her diversion of resources to independent treatment centres. Political advantage

Hewitt has one big political advantage. Her plans for primary care do not require legislation, so there will be no clear opportunity for a backbench revolt.

The first signal of the course she intends to pursue is likely to come on Friday in a speech to the NHS Alliance. According to Hewitt's department, she is expected to say that the "overriding message" from the Birmingham event was that people want to be able to see a GP or other primary care professional at a time to suit their busy lifestyles. She will argue: "Banks and supermarkets are open seven days a week, and GP services need to catch up." That might include extending the role of of nurses and pharmacists to provide an alternative to seeing the GP. The aim would be to give all patients a choice shaping how services are delivered.

But will that choice include the independent sector? Hewitt has yet to reveal her hand. It would be surprising if she abandoned support for introducing the stimulus of competition from private providers. But her white paper will be a statement of her vision of primary care services. It will be left to PCTs to consult and negotiate locally on what patients want and what the providers will wear.